Controlled substances have gotten a little less controlled during the pandemic. This has benefited both patients (for their health) and telehealth startups (for making money).
Some potentially addictive drugs, such as buprenorphine and Adderall, are now much more available online to patients due to regulatory changes. Given the shortage of physicians qualified to treat some of the behavioral health conditions associated with these drugs, such as opioid use disorder or attention-deficit/hyperactivity disorder, the new ability of physicians to prescribe online or, in some cases, over the phone represents a huge change. But easier access to drugs has both advantages and disadvantages, since they are often dispensed without accompanying therapy that improves a patient’s chances of success.
Before the pandemic, patients sometimes traveled several hours for addiction treatment, said Emily Behar, director of clinical operations for Ophelia, a New York startup serving people with opioid addictions. Or patients may be grappling with multiple jobs or a lack of childcare. These obstacles made maintaining care burdensome.
“How do you reach those people?” she asked.
It’s a question that worries much of the behavioral health industry, complicated by the reality that most patients with opioid use disorder are not being treated, said Dr. Neeraj Gandotra, medical director of the Substance Abuse and Mental Health Services Administration. .
Greater access to telehealth has begun to provide an answer. Behar, the startup executive, says his patients can see expert providers at their convenience. Missed appointments are decreasing, say many in the industry.
The startup has secured solid funding — nearly $68 million, according to Crunchbase, an industry database — but addiction specialists and other online controlled substance prescribers are a mixed bunch. Some are nonprofits; others are large startups that attract media and law enforcement scrutiny for alleged sloppy prescribing practices.
The influx of new suppliers is attributable to the easing of requirements born out of pandemic-era necessity. To help patients access care while maintaining physical distance, the Drug Enforcement Administration and SAMHSA have lifted restrictions on telehealth for controlled substances.
But whether these changes will last is uncertain. The federal government is working piecemeal to codify new rules for prescribing controlled substances, in light of the healthcare system’s pandemic experience.
On Dec. 13, SAMHSA issued a proposal to codify telehealth regulations on opioid treatment programs, but that only affects part of the industry. Left unaddressed — at least until the DEA issues the rules — is the process for individual providers to sign up to prescribe buprenorphine. The new rules “get us at least a little bit closer to where we need to go,” said Sunny Levine, a telehealth and behavioral health attorney at the Milwaukee-based firm of Foley & Lardner.
Congress also changed the buprenorphine rules, eliminating a long-standing policy to limit the number of patients each provider can prescribe to. Ultimately, however, the DEA is the major regulatory domain that has yet to fall for telehealth providers.
Additionally, pharmacies are taking a more skeptical stance on telehealth prescriptions, especially from startups. Patients were getting used to using telehealth to fill and refill their medication prescriptions for some controlled substances, such as Adderall, which is mainly used for the treatment of ADHD. A shortage of Adderall has compromised access for some patients. Now, though, some pharmacies are refusing to fill those prescriptions.
Cheryl Anderson, a Pennsylvanian with ADHD, said she’s been looking for online options because of her busy schedule.
“My husband is often out of town, so I don’t have someone to reliably watch the kid to go on an in-person appointment,” she said. It was difficult, with three children, to find the time. Telehealth has been helping for about half of 2022. Previously, the DEA and state governments imposed strict rules on obtaining controlled substances from online pharmacies.
But in September, after her doctor wrote a refill prescription, she received a phone call saying her local pharmacy would not dispense drugs if the prescription came via telehealth. Other local pharmacies she called have taken the same stance.
Those denials appear to reflect a broader cultural shift in attitudes. While patients and policymakers hailed telehealth early in the pandemic — first for its safety but also for its greater convenience and potential to extend care to rural areas and neighborhoods without specialists — hints of skepticism are creeping in. .
The telehealth boom has attracted shady actors. “A lot of people have seen an opportunity to do less than scrupulous things,” particularly in the behavioral health market, said Michael Yang, managing partner at venture capitalist firm OMERS Ventures. Skeptical media coverage of startups that allegedly prescribe shotguns for mental health conditions without monitoring the patients receiving those drugs has proliferated. “It will settle down.”
Startups pose dilemmas for local pharmacists, said Matt Morrison, owner of Gibson’s Pharmacy in Dodge City, Kansas.
Pharmacists have multiple prescription-related obligations, she said: Make sure incoming prescriptions are from legitimate doctors and are related to an actual health condition before filling the order. The feeling in the industry, Morrison said, is that startup prescriptions are complicated. They may come from a distant supplier, who the pharmacist cannot easily contact.
Those qualms pose difficulties for addiction treatment. Getting pharmacists to fill prescriptions is one of Ofelia’s biggest administrative tasks, Behar said. However, going online was helpful.
“Telehealth fills the gaps,” said Josh Luftig, a founding member of CA Bridge, an Oakland, California-based program that helps patients in emergency departments get started on substance abuse treatment. The supply of healthcare workers was not sufficient to meet the demand. “Across the board, there has been a lack of access to outpatient care. Now all they need is a phone and getting to a pharmacy.”
The treatment is more efficient for both the patient and the provider, the providers say. “Most of our patients prefer to have a telehealth experience,” she said. “Telehealth appointments are more efficient. It increases the capacity of each person involved”.
Established organizations are also reporting success: Geisinger, a large Mid-Atlantic health system, said 94 percent of participants in a program focused on motherhood were compliant, spokesperson Emile Lee said.
Ophelia, which started just before the pandemic, planned to treat patients both in-office and online. “We have an office in Philadelphia that we’ve never used,” she said. Now the company works every few months — in anticipation of the end of state and federal public health emergencies — to make sure the end of the associated looser rules doesn’t lead to disruptions in the care of its patients.
Greater clarity on the future of online processing could come from permanent DEA regulations. What the agency rule — which would create a registration process for providers interested in prescribing controlled substances online — will say is “whoever guesses,” said Elliot Vice, a telehealth executive with trade group Faegre Drinker. That rule has been hanging for years. “Seeing this still not moving, it’s disconcerting.”
The agency, which declined to comment specifically on this article, pointed to previous statements lauding increased access to drug-assisted treatment.
“There shouldn’t be any changes in the rules for telehealth,” Luftig said. “That would be the most horrific thing in terms of access for our communities. It would be an absolute disaster.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the three major operational programs of the KFF (Kaiser Family Foundation). KFF is a gifted non-profit organization that provides information on health issues to the nation.